Definition and Overview
Psychogenic dizziness is dizziness that occurs when psychological factors such as anxiety, fear, and stress affect vestibular function processing without structural vestibular disease or central nervous system lesion. Approximately 20-30% of patients who visit specialized clinics for chronic dizziness are diagnosed with psychogenic causes. In the past, it was called 'nervous dizziness' or 'phobic postural vertigo', and recently, it is being re-established as a diagnostic system called persistent postural-perceptual vertigo (PPPD).
Psychogenic dizziness is a symptom that patients actually experience, and is not ‘made up’ or ‘caused by mental weakness.’ It is a neurological phenomenon caused by excessive activation of the brain's anxiety-vestibular interaction circuit, and functional magnetic resonance imaging (fMRI) studies have confirmed changes in activity in related brain regions.
Causes and Mechanisms
Anxiety-Vestibular Interactions
Dizziness and anxiety are closely linked neuroanatomically. A bidirectional neural pathway exists between the vestibular nucleus, the amygdala, hippocampus, and brainstem autonomic centers. Anxiety disrupts vestibular signal processing, and dizziness amplifies anxiety, creating a vicious cycle. Balaban and Thayer (2001) named this circuit the 'balance-anxiety link' and reported that the parabrachial nucleus pathway connecting the vestibular nucleus and amygdala plays a key relay role.
autonomic nervous system hyperactivity
Chronic overactivity of the sympathetic nervous system is commonly observed in patients with psychogenic dizziness. Abnormalities in sympathetic-parasympathetic balance are confirmed in heart rate variability (HRV) analysis, and excessive sympathetic nerve response worsens dizziness when standing. Norepinephrine, which is secreted during sympathetic overactivity, lowers the dizziness threshold by modulating signal processing in the vestibular nucleus. This causes excessive dizziness even with normal head movements or changes in position.
hyperventilation mechanism
Hyperventilation is a direct cause of psychogenic dizziness. When breathing becomes faster during anxiety, the partial pressure of carbon dioxide in the blood decreases and respiratory alkalosis occurs. As a result, cerebral blood vessels contract, cerebral blood flow decreases, and symptoms such as dizziness, blurred vision, and numbness in the limbs appear. Studies have shown that in approximately 25% of patients with chronic dizziness, symptoms are reproduced when tested to induce hyperventilation.
The role of the insular cortex
The insula is a center that integrates vestibular information, visceral sensation (interoception), and emotional processing. Indovina et al. According to a study by (2015), in people with high anxiety tendencies, the connectivity between the insula and amygdala abnormally increases during vestibular stimulation, and dizziness and anxiety are mutually reinforced. This finding provides evidence that psychogenic dizziness is not a simple psychological problem, but reflects functional changes at the brain circuit level.
related diseases
panic disorder
Acute dizziness occurs during a panic attack, and approximately 50-85% of patients with panic disorder experience dizziness. As panic attacks repeat, anticipatory anxiety that 'I'm going to get dizzy again' is formed, which in itself causes dizziness, creating a vicious cycle.
generalized anxiety disorder
Constant worry and tension chronically activate the sympathetic nervous system, causing mild but persistent feelings of dizziness and instability. The prevalence of nonrotational dizziness in patients with generalized anxiety disorder is approximately 2 to 3 times higher than in the general population.
Relationship with PPPD
A significant proportion of psychogenic dizziness is currently being reclassified as persistent postural-perceptual dizziness (PPPD). PPPD is a diagnosis established by the Bárány Society in 2017 and integrates several existing diagnostic concepts such as chronic subjective dizziness, phobic positional vertigo, and visual-dependent dizziness. Among psychogenic dizziness, if non-rotational dizziness and unsteadiness persist for more than 3 months and are worsened by standing upright, walking, or visual stimulation, the diagnostic criteria for PPPD are met.
symptoms
The symptoms of psychogenic dizziness are different from structural vestibular diseases. The main symptoms are as follows:
- Non-rotational dizziness: Characterized by a feeling of floating rather than a spinning feeling, a feeling of lightheadedness, and a feeling of instability as if the floor is shaking.
- Situational dependence: Worsened in crowded places (mart, subway), large spaces, high places, and under bright lights. On the other hand, it is often alleviated at home or in a safe environment.
- Autonomic symptoms include: increased heart rate, sweating, numbness in the hands and feet, chest tightness, and shortness of breath along with dizziness.
- Variability: The intensity of symptoms fluctuates throughout the day and worsens during times of stress, fatigue, or lack of sleep.
- Symptoms related to hyperventilation: As breathing becomes faster, dizziness, blurred vision, and numbness in the limbs appear simultaneously.
Even if true vertigo is the main symptom, an acute vertigo attack may occur if anxiety disorders such as panic disorder are present, so differentiation is necessary.
diagnosis
Vestibular function test
The diagnosis of psychogenic dizziness is basically a diagnosis of exclusion. Structural vestibular disease should be excluded through vestibular function tests such as videonystagmography (VNG), caloric test, video head impulse test (vHIT), and vestibular evoked muscle potential (VEMP). Central lesions such as the cerebellum and brainstem are also confirmed through MRI.
mental health assessment
Psychological factors such as anxiety, depression, and panic disorder are systematically evaluated. Standardized survey tools such as PHQ-9 (Patient Health Questionnaire), GAD-7 (Generalized Anxiety Disorder Scale), and DHI (Dizziness Disorder Inventory) are used. If the patient's dizziness symptoms are reproduced during the hyperventilation induction test, it will be helpful for diagnosis.
autonomic nerve test
Autonomic dysfunction is objectively assessed through tilt table test, heart rate variability (HRV) analysis, and Valsalva maneuver. If sympathetic nerve hyperactivity is confirmed, it is useful in explaining the mechanism of psychogenic dizziness and establishing a treatment plan.
Differential diagnosis
Psychogenic dizziness must be differentiated from structural and functional vestibular diseases such as BPPV, vestibular neuritis, Meniere's disease, and migraine-related dizziness. In particular, the 'overlap pattern', in which psychogenic dizziness overlaps secondary to vestibular disease, is common, so the possibility of two diagnoses existing simultaneously should always be considered.
treatment
Cognitive Behavioral Therapy (CBT)
Cognitive behavioral therapy (CBT) is a key treatment for psychogenic dizziness. Correct catastrophic interpretations of dizziness ('I'm going to fall', 'I have a serious brain disease') and gradually reduce avoidance behavior. According to the study, the frequency and severity of dizziness significantly decreased in patients with chronic dizziness who received CBT.
vestibular rehabilitation treatment
Vestibular rehabilitation includes balance training, gaze stabilization exercises, and habituation training. Gradual exposure to dizziness-inducing stimuli reduces the brain's hypervigilance response and restores normal balance processing. In patients with high visual dependence, training to reduce visual dependence is added.
SSRI drug treatment
Selective serotonin reuptake inhibitors (SSRIs) are effective in controlling hyperactivity of the anxio-vestibular circuit. Sertraline, escitalopram, paroxetine, etc. are used, and according to studies, symptom improvement was reported in about 50-70% of patients with chronic subjective dizziness after SSRI treatment. It takes 4 to 8 weeks for the effect to appear, so you must continue taking it for a sufficient period of time.
breathing training
If hyperventilation is confirmed to be a factor that causes or worsens dizziness, diaphragmatic breathing training is included in the treatment. Repeated training of a slow breathing pattern of 4 seconds inhalation and 6 seconds exhalation activates the parasympathetic nerve (vagus nerve) and relieves overactivity of the sympathetic nerve. Breathing training is useful as a self-management tool because patients can perform it autonomously in their daily lives.
autonomic nerve control treatment
Autonomic nerve control treatment is applied to patients with confirmed sympathetic overactivity and autonomic imbalance. Heart rate variability biofeedback (HRV biofeedback), transcranial direct current stimulation (tDCS), and vagus nerve stimulation are being studied, and the goal is to normalize dizziness threshold by restoring autonomic balance.
Progress and prognosis
The natural course of psychogenic dizziness varies greatly from person to person. If left untreated, it can become chronic and last for years, and daily activities and social functions can gradually decline as avoidance behavior becomes stronger. If an accurate diagnosis is made early and cognitive behavioral therapy, drug therapy, and vestibular rehabilitation are combined, the prognosis is good. Dieterich and Staab (2017) reported that when a multidisciplinary approach was applied, significant symptom improvement was observed in approximately 60-80% of patients.
The main factors that affect prognosis are the duration of symptoms (the shorter the better), whether concurrent mental health disorders are treated, and the patient's understanding of the disease and participation in treatment. Just explaining that 'the test is normal so it's okay' does not relieve the patient's pain, and the first step in treatment is to fully explain that dizziness is a treatable condition with an actual neurological mechanism.